What are the considerations for restarting Vyvanse (lisdexamfetamine) therapy?

Considerations for Restarting Vyvanse (Lisdexamfetamine) Therapy

When restarting Vyvanse (lisdexamfetamine) therapy, begin with a lower dose than previously used and gradually titrate up to the therapeutic dose, especially if the medication has been discontinued for more than 3-4 half-lives.

Assessment Before Restarting

Before reinitiating Vyvanse therapy, consider the following key factors:

Medical Evaluation

• Cardiovascular status: Screen for structural cardiac abnormalities, cardiomyopathy, serious cardiac arrhythmia, coronary artery disease, or other serious cardiac conditions 1
• Vital signs: Measure baseline blood pressure and heart rate, as Vyvanse can increase BP by 2-4 mmHg and HR by 3-6 bpm 1
• Psychiatric evaluation: Screen for:
  • Pre-existing psychosis that could be exacerbated
  • Risk factors for bipolar disorder or manic episodes
  • History of tics or Tourette's syndrome 1

Duration of Discontinuation

• If Vyvanse has been stopped for more than 3-4 half-lives (approximately 3-4 days), consider using a lower starting dose 2
• The need for repeating loading doses depends on:
  • Disease severity (symptom intensity)
  • Duration of discontinuation
  • Patient's current symptom status 2

Dosing Recommendations for Restart

Initial Dosing

• Starting dose: Begin with 20-30 mg once daily in the morning 2
• Titration: Increase by 10 mg weekly increments to reach effective dose 2
• Maximum dose: Up to 70 mg daily 2

Special Populations

• For patients with significant cardiovascular risk: Consider starting at lower doses with more gradual titration
• For patients with history of substance use disorder: Implement more frequent monitoring due to abuse potential 1

Monitoring After Restart

Short-term Monitoring (First Month)

• Vital signs: Monitor blood pressure and heart rate at each visit
• Side effects: Assess for common adverse effects:
  • Decreased appetite (reported in 25-39% of patients)
  • Insomnia (reported in 11-19% of patients)
  • Headache
  • Dry mouth 3

Long-term Monitoring

• Growth parameters in pediatric patients: Monitor height and weight regularly as CNS stimulants can cause weight loss and slowing of growth 1
• Cardiovascular parameters: Regular monitoring of blood pressure and heart rate
• Psychiatric symptoms: Monitor for emergence of:
  • Psychotic or manic symptoms
  • Tics or worsening of Tourette's syndrome
  • Signs of serotonin syndrome if combined with serotonergic medications 1

Potential Complications and Management

Common Side Effects

• Appetite suppression/weight loss: Monitor weight; consider nutritional counseling
• Sleep disturbances: Recommend proper sleep hygiene; ensure morning dosing
• Cardiovascular effects: Monitor for tachycardia and hypertension 3

Serious Adverse Events

• Psychiatric adverse reactions: If new psychotic or manic symptoms occur, consider discontinuation
• Peripheral vasculopathy: Monitor for digital changes; refer to rheumatology if signs develop
• Serotonin syndrome: Avoid combinations with MAOIs; use caution with SSRIs, SNRIs, and other serotonergic medications 1

Contraindications for Restart

• History of allergic reaction to lisdexamfetamine or its components
• Concurrent use of MAOIs or within 14 days of MAOI use
• Advanced arteriosclerosis, symptomatic cardiovascular disease, moderate to severe hypertension
• Hyperthyroidism
• Known hypersensitivity or idiosyncrasy to sympathomimetic amines 1

Special Considerations

Drug Interactions

• Serotonergic medications: Monitor for serotonin syndrome when combining with SSRIs, SNRIs, triptans, etc.
• CYP2D6 inhibitors: May increase exposure to dextroamphetamine (active metabolite)
• Antihypertensives: May decrease effectiveness of these medications 1

Abuse Potential

• Lisdexamfetamine has lower abuse potential than immediate-release stimulants due to its prodrug formulation 3
• Regular assessment for signs of misuse, abuse, or diversion is still necessary 1

Remember that restarting Vyvanse should be approached with careful consideration of the patient's current symptoms, medical status, and the reason for previous discontinuation. The goal is to balance symptom control with minimizing potential adverse effects.